Codeine Toxicity in a Hemodialysis-dependent Child: A Rare Case of Prolonged Neurologic Complications Codeine Toxicity in Hemodialysis
Journal of Pediatric Nephrology,
Vol. 13 No. 1 (2025),
12 May 2026
https://doi.org/10.22037/jpn.v13i1.50246
Abstract
Background and Aim: Chronic kidney disease (CKD) is one of the most important problems
in children, sometimes associated with many co-morbid problems, such as intractable pain.
The pharmacokinetics of almost all analgesics are very different in CKD patients compared
to the normal population. Because of the accumulation of toxic metabolites, many of the
commonly used pain medications have more adverse effects and increased potential for
central nervous system toxicity.
Case Presentation: We reported an eleven-year-old girl affected by end-stage renal disease
(ESRD) due to focal segmental glomerolosclerosis (FSGS) nephrotic syndrome who
presented with decreased level of consciousness, behavioral dysfunction, and neurological
complications following a small dose of codeine consumption.
Conclusion: Even small doses of codeine can lead to severe, prolonged neurotoxicity in
pediatric ESRD. Appropriate drug selection and dosing in patients with CKD is necessary
to ensure optimal outcomes and avoid unwanted complications. Prescribing a standard dose
of analgesics without consideration of the patient’s renal function state may cause serious
complications.
- Codeine
- Opioid
- Drug toxicity
- Hemodialysis
- Pediatric Nephrology
How to Cite
References
[1] Coluzzi F, Caputi FF, Billeci D, Pastore AL, Candeletti S,
Rocco M, et al. Safe use of opioids in chronic kidney disease
and hemodialysis patients: Tips and tricks for non-pain specialists.
Ther Clin Risk Manag. 2020; 16:821-37. [DOI:10.2147/
TCRM.S262843] [PMID]
[2] Yamamoto S, Kazama JJ, Maruyama H, Nishi S, Narita I,
Gejyo F. Patients undergoing dialysis therapy for 30 years
or more survive with serious osteoarticular disorders. Clin
Nephrol. 2008; 70(6):496-502. [DOI:10.5414/CNP70496]
[PMID]
[3] Davison SN, Koncicki H, Brennan F. Pain in chronic kidney
disease: A scoping review. Semin Dial. 2014; 27(2):188-204.
[DOI:10.1111/sdi.12196] [PMID]
[4] Rodieux F, Wilbaux M, van den Anker JN, Pfister M. Effect
of kidney function on drug kinetics and dosing in neonates,
infants, and children. Clin Pharmacokinet. 2015; 54(12):1183-
204. [DOI:10.1007/s40262-015-0298-7] [PMID]
[5] Kamarzarian A, Pham PMT, Pham PTT. Pharmacology. In:
Pham PC, Pham PT, editors. Nephrology and hypertension
board review. Philadelphia: Wolters Kluwer, 2016. [Link]
[6] Triantafylidis LK, Hawley CE, Perry LP, Paik JM. The role
of deprescribing in older adults with chronic kidney disease.
Drugs Aging. 2018; 35(11):973-84. [DOI:10.1007/s40266-018-
0593-8] [PMID]
[7] Pergolizzi JV Jr, Breve F, Taylor R Jr, Raffa RB, Strasburger
SE, LeQuang JA. Considering tapentadol as a first-line analgesic:
14 questions. Pain Manag. 2017; 7(4):331-9. [DOI:10.2217/
pmt-2016-0063] [PMID]
[8] Calls Ginesta J, Rodriguez Calero MA, Hernández Sánchez
D, Gutierrez Navarro MJ, Juan Amer F, Tura Rosales D, et
al. An evaluation of pain in haemodialysis patients using
different validated measurement scales. Nefrología. 2009;
29(3):236-43. [Link]
[9] Pham PC, Toscano E, Pham PM, Pham PA, Pham SV, Pham
PT. Pain management in patients with chronic kidney disease.
NDT Plus. 2009; 2(2):111-8. [DOI:10.1093/ndtplus/
sfp001] [PMID]
[10] Brintz CE, Cheatle MD, Dember LM, Heapy AA, Jhamb M,
Shallcross AJ, et al. Nonpharmacologic treatments for opioid
reduction in patients with advanced chronic kidney disease.
Semin Nephrol. 2021; 41(1):68-81. [DOI:10.1016/j.semnephrol.
2021.02.007] [PMID]
[11] Pham PC, Khaing K, Sievers TM, Pham PM, Miller JM,
Pham SV, et al. 2017 update on pain management in patients
with chronic kidney disease. Clin Kidney J. 2017; 10(5):688-97.
[DOI:10.1093/ckj/sfx080] [PMID]
[12] Mrabet S, Attia S, Chaieb R. Pain assessment, management
and impact among Hemodialysis patients: A study from Tunisia.
BMC Nurs. 2025; 24(1):581. [DOI:10.1186/s12912-025-
03130-9] [PMID]
[13] Marzouq MK, Samoudi AF, Samara A, Zyoud SH, Al-Jabi
SW. Exploring factors associated with pain in hemodialysis
patients: A multicenter cross-sectional study from Palestine.
BMC Nephrol. 2021; 22(1):96. [DOI:10.1186/s12882-021-
02305-1] [PMID]
[14] Wang JS, Chiang JH, Hsu HJ. Lower risk of musculoskeletal
pain among patients with end-stage renal disease
treated by hemodialysis: A frequency-matched retrospective
cohort study. Medicine. 2018; 97(33):e11935. [DOI:10.1097/
MD.0000000000011935] [PMID]
[15] Dos Santos PR, Mendonça CR, Noll M, Borges CC, Alves
PM, Dias NT, et al. Pain in hemodialysis patients: prevalence,
intensity, location, and functional interference in daily
activities. Healthcare. 2021; 9(10):1375. [DOI:10.3390/healthcare9101375]
[PMID]
- Abstract Viewed: 27 times
- pdf Downloaded: 8 times